A paper published in The BMJ summarizes the clinical importance of evaluating thyroid nodules, focuses on the clinical evidence for diagnostic tests, and highlights the importance of considering the patient’s values and preferences when deciding on management strategies regarding the uncertainty about the risk of thyroid cancer.1
According to the review, the incidence of thyroid cancer has increased over the past 3 to 4 decades, though the mortality from thyroid cancer has remained stable. In the US, the incidence was found to increase from 3.6 per 100,000 in 1973 to 8.7 per 100,000 in 2002.
“Imaging technology is more widely available than ever before, which is a good thing. But any imaging that includes the neck can detect a thyroid nodule, and these nodules are present in about 60% of the population,” lead author Naykky Singh Ospina, MD, assistant professor in the UF College of Medicine’s division of endocrinology, diabetes, and metabolism and a member of the UF Health Cancer Center, said in a news release.2 “That incidental indirect screening contributes to thyroid cancer being one of the most common cancer diagnoses. And that can lead to over treatment.”
Singh Ospina noted that the goal of the paper was to explain that a large number of thyroid nodules could be monitored without biopsy, which would save patients from being exposed to potential complications and the cost of unnecessary treatment. Additionally, many small and low-risk thyroid cancers would pose no risk to patients if it they were to continue to be undiagnosed and untreated.
The authors identified 3 “critical” moments in a patient’s experience relative to a diagnosis of thyroid nodules. The first is the detection of the thyroid nodules, the second is the decision between performing a fine needle aspiration (FNA) or follow-up with serial ultrasound, and the third is, once FNA results are available, the pre-test probability of thyroid cancer that was derived from pre-biopsy testing should not be forgotten and should estimate an new risk for thyroid cancer.
“It’s critically important to have a discussion with the patient about the best approach given their situation, clinical presentation, and their estimated risk of thyroid cancer,” said Singh Ospina. “We hope physicians discuss the clinical evidence and collaborate with patients when making the decision on whether to do a biopsy or monitor with ultrasound. The goal is that this collaboration leads to decisions that make sense to the patients too.”
The researchers indicated that management recommendations should depend on the certainty of underlying malignant process and, ideally, the likelihood of a clinically relevant malignancy. In patients who are found to have benign disease, surgery should be reserved for symptomatic disease. For those with malignancy, surgery is normally recommended, with the extent of surgery governed by initial clinical features and active surveillance considered for those with micro-papillary thyroid cancer (PTC). Further, should patients present with indeterminate thyroid nodules, the next step in management depends on the patient’s risk after diagnostic evaluation and consideration of the values, preferences, and context of the patient.
“It’s important to understand the danger aggressive types of thyroid cancer can pose, including death,” Singh Ospina explained. “Additionally, certain types of thyroid cancer can cause a lot of morbidity and complications. The key is knowing which thyroid cancers are aggressive and require immediate diagnosis and treatment and which are less aggressive and might be monitored without surgery.”
Several guidelines are available in regard to the evaluation of thyroid nodules according to the authors, however there are variations in the frequency of ultrasound assessment recommended. Moreover, the use of molecular markers in routine clinical practice is not recommended by each of the guidelines. Overall, the paper highlights the importance of avoiding a linear evaluation and consulting with patients in regard to their treatment and diagnosis.
1. Singh Ospina N, Iñiguez-Ariza NM, Castro MR. Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment. The BMJ 2020; 368. doi:10.1136/bmj.l6670.
2. UF Health study provides guidance to avoid unnecessary thyroid biopsies [news release]. Florida. Published March 4, 2020. ufhealth.org/news/2020/uf-health-study-provides-guidance-avoid-unnecessary-thyroid-biopsies. Accessed March 4, 2020.